Acta Dermato-Venereologica 99-2CompleteContent | Page 33
244
SHORT COMMUNICATION
A Case of Generalized Interstitial Granuloma Annulare and Arthritis Associated with Breast Cancer
Ariane CLAPÉ 1 , Clélia VANHAECKE 1 *, Anne DURLACH 2 , Philippe BERNARD 1 , Christelle JOUANNAUD 3 , Laurie KPODAR 4 ,
Bernard CRIBIER 5 and Manuelle VIGUIER 1
1
Department of Dermatology, Reims University Hospital, University of Reims Champagne-Ardenne, Avenue du general Koenig, FR-51092
Reims Cedex, 2 Biopathology, Hospital Maison Blanche, Reims University Hospital, 3 Department of Medical Oncology, Jean Godinot Institut,
Reims, 4 Department of Rheumatology, Manchester Hospital, Charleville Mézières, and 5 Dermatopathology and Dermatology, Faculty of
Medicine, University of Strasbourg, University Hospital of Strasbourg, Strasbourg, France. *E-mail: [email protected]
Accepted Oct 3, 2018; E-published Oct 3, 2018
Granuloma annulare (GA) is a benign inflammatory skin
disease of unknown origin, classically presenting with
self-limited, skin-coloured to erythematous, papules with
ring-shaped distribution with no epidermal changes, of-
ten located on the dorsal surfaces of the hands and feet.
Several clinical variants of GA have been described,
including generalized GA, subcutaneous GA, and per-
forating GA. GA shows typically palisading granulomas
with a central zone of necrobiotic collagen surrounded
by a palisade of histiocytes associated with mucin
deposition. An interstitial histopathological pattern
is also described, consisting of lymphohistiocytic in-
filtrate scattered between and around collagen bundles
and around blood vessels in the reticular and papillar
dermis. Finally, subcutaneous histopathological patterns
are also reported.
With the exception of diabetes, no consistently as-
sociated systemic disorder is identified in GA, and it is
not usually considered as a paraneoplastic syndrome.
We report here an unusual case of diffuse interstitial
generalized GA in association with breast cancer.
CASE REPORT
A 45-year-old woman was referred to our dermatology unit with
a 4-month history of an extensive rash with large erythematous
pruritic papulous plaques (Fig. 1 a, b). The lesions initially invol-
ved sun-exposed sites, and rapidly spread on the limbs, trunk and
face with no eyelid involvement. The patient reported symmetrical
polyarthritis of the ankles, knees and wrists, in association with
high-grade fever, marked asthenia and 15 kg weight loss. No
myalgia, motor deficit or synovitis was present. Physical examina-
tion revealed a voluminous left mammary tumour T2 (5 cm) and
palpable axillary lymph nodes N1 (6 cm). Her medical history
was marked by diabetes mellitus (DM) and dyslipidaemia. Crea-
tine kinase and aldolase concentrations were normal, antinuclear
antibodies titre was 1:400 with speckled pattern. Tests for anti-
extractable nuclear antibodies, anti-double-stranded DNA, anti
J0-1 antibodies, rheumatoid factor and anti-cyclic citrullinated
peptide antibodies were negative. There was no specific radiolo-
gical damage in the peripheral joints. Cutaneous biopsies revealed
a histiocytic infiltrate, with no multinucleated giant cells, in an
interstitial and diffuse pattern from the papillary to the reticular
dermis, with no interface dermatitis. Immunohistochemical stains
showed diffuse CD68 + and CD163 + histiocytes (Fig. 2).
The clinical presentation and histopathological findings led
to the diagnosis of diffuse interstitial generalized GA. Breast
biopsy revealed an invasive papillary carcinoma, SBR (Scarff
Bloom Richardson) III, mitotic index 2, no embolus, oestrogen-
receptor-positive (10%), progesterone-receptor-negative, human
doi: 10.2340/00015555-3056
Acta Derm Venereol 2019; 99: 244–245
epidermal growth factor receptor type 2 (HER2) 1+. Whole-body
18-fluorodeoxyglucose positron emission tomography detected
left axillary lymph node metastasis, but no distant metastasis. The
patient was treated with a neoadjuvant chemotherapy, including 5
fluorouracil, epirubicin and cyclophosphamide (FEC 100 protocol)
and transient oral morphine for joint pain. Complete resolution
of arthritis and cutaneous manifestations was reported 2 months
after the onset of chemotherapy, with no other specific treatment
(Fig. 1c, d). No recurrence of the eruption was observed during
the whole treatment (4 cycles of FEC 100, 12 perfusions of taxol,
tumorectomy and axillary lymphadenectomy, radiotherapy) and
under current hormonotherapy with a follow-up of 14 months. To
date, the cancer is in remission.
DISCUSSION
The clinical presentation of this patient was atypical for
GA, with large erythematous papulous plaques with an
active border, involving a large skin surface. The lack of
annular disposition was particularly puzzling; neverthe-
less, non-annular lesions are usual in the generalized
variety of GA (1, 2). The diagnosis of multicentric reti-
culohistiocytosis (MRH) could also have been suspected
because of concomitant polyarthritis and association
with tumoural syndrome. Indeed, this rare systemic
Fig. 1. Clinical photographys at the time of breast cancer diagnosis,
showing symmetrically large erythematous papulous plaques
involving: (a) chest; (b) thigh, after 2 cycles of neoadjuvant chemotherapy
for breast cancer with residual post-inflammatory pigmentation involving
the same locations as the initial lesions: (c) chest and (d) thigh.
This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta
Journal Compilation © 2019 Acta Dermato-Venereologica.